Why No One Saved Gabriel Fernandez

On September 13, 2018, a Los Angeles County judge denied a motion to dismiss felony child abuse and falsification of records charges against four former child welfare caseworkers in the 2013 death of ten-year-old Gabriel Fernandez. The charges, filed in 2016, marked the first time Los Angeles caseworkers were criminally charged for misconduct connected with their work, and is one of only a few similar cases nationwide.

If Gabriel’s case is one of the few child deaths to result in prosecution of state workers, the egregious nature of the state’s failure explains why. A brilliant article by investigative reporter Garret Therolf shows that for seventh months, evidence of Gabriel’s abuse steadily accumulated. Yet again and again, the Los Angeles Department of Child and Family Services (DCFS) failed to intervene. Some of the worst errors are listed below.

Gabriel’s mother had been the subject of at least four calls to the child abuse hotline, had abandoned one child, and had lost custody of a son a year older than Gabriel. Yet, this record was never reviewed by workers investigating multiple reports of suspicious injuries to Gabriel.

Each time investigators came to the home, they interviewed Gabriel and his siblings with his mother in the room, against agency policy and common sense. And each time they did so, he recanted his previous statements. Even after he came to school with his face full of bruises from being shot by his mother with a BB gun, he recanted and told the investigator the injuries were from playing tag with his siblings. In the face of visible evidence, the investigators repeatedly chose to believe the repeated recantations

Investigators never spoke with neighbors or school personnel (other than the teacher who reported the abuse) but according to Therolf the abuse was known widely among school staff.

A computer program had found Gabriel to be at “very high risk” of abuse, requiring that the case be “promoted,” usually involving asking a court to require services or foster care. But the investigator, backed up by her supervisor, referred Gabriel’s mother to voluntary family services. Gabriel’s mother Pearl Fernandez withdrew from these services after three visits.

During the brief period of voluntary services, Gabriel wrote several notes saying he wanted to kill himself. Gabriel’s therapist informed the caseworker and supervisor, but they took no action.

The therapist had grown concerned that Gabriel was being abused, but her supervisor told her not to call the hotline so as not to jeopardize the mother’s participation in the voluntary case.

After three visits, Pearl Fernandez asked for her voluntary case to be closed. The caseworker accepted her decision, stating that there were no safety or risk factors for the children. Contrary to policy, her supervisor signed off on the case closure without reading the file.

After the case was closed, a security guard at the welfare office saw Gabriel covered with cigarette burns and other marks and being yelled at by his mother. The called DCFS twice and got lost in the automated system. The 911 operator gave him the non emergency line, which he called. He was later told that a sheriff’s deputy had gone to the home and seen nothing wrong.

Gabriel’s teacher, who had lost hope of any rescue from DCFS, called the DCFS investigator one more time late in April when Gabriel showed up looking worse than she had ever seen him. One eye was blood-red, skin was peeling off his forehead, and other marks were on his face, neck and ear. Her call was never returned. Gabriel had only about a month left to live.

Investigators later learned that during the weeks before his death, Gabriel was spending days and nights locked in a cabinet with a sock in his mouth, hands tied, a bandanna over his face, and handcuffs on his ankles. His solitude was interrupted by vicious beatings and torture sessions in which his siblings were required to participate. On May 22, Pearl and Aguirre tortured Gabriel a final time with a BB gun, pepper spray, coat hangers and a baseball bat. When they finally called 911, paramedics found two skull fractures, broken ribs, several teeth knocked out, BB gun pellet marks, cigarette burns on his feet and genitals, a skinned neck, and cat feces in his throat.

Therolf poses a key question regarding Gabriel’s death: “Was [the] failure …to protect Gabriel an isolated one—the fault of four employees so careless and neglectful that they allowed a child to suffer despite a series of glaring warning signs? Or was it a systemic one, the result of a department so ill-equipped to safeguard children that tragedies were bound to happen?”

While Therolf does not actually answer the question, his report offers a number of key findings and insights that point strongly in the direction of systemic factors as the prime contributors to the failure to protect Gabriel. Therolf found that many of the errors made by investigators, such as failure to interview children alone or to speak with witnesses outside the family, were prevalent in Los Angeles County. Sadly, many of the same failures were evident in the very recent case of Anthony Avalos, also in Los Angeles. And we also see similar failures , and in cases around the country, including Kansas, New York, and Oregon.

The systemic factors that cause these failures fall into two major categories–resource constraints and ideological factors.

Resource Constraints

Child welfare involves a balancing act between too much intervention or “erring on the side of child safety” as Therolf puts it and too little or “erring on the side of family preservation.” Striking this critical balance requires a combination of knowledge, skill, and time. In other words, as Therolf puts it, “it requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Therolf rightly contends that most agencies don’t have these resources. One has only to read the constant stream of news reports of overwhelming caseloads and poor training of child welfare workers around the country. All of this reflects the unwillingness of taxpayers and legislatures to provide what is needed to protect children. Inadequate funds mean caseloads are too high and salaries are too low, both resulting in low standards for caseworkers.

More funding and could buy both lower caseloads and higher salaries, which are necessary to obtain more qualified investigative workers. After reading so many similar stories, and recalling my own rudimentary training as a Child Protective Services (CPS) worker I am beginning to think that ultimately CPS Investigation should be a specialty in Masters in Social Work Programs. Students would learn advanced interviewing skills and how to assess the truthfulness of children and adults rather than, for example, believing children when they recant allegations with their parents in the room. Alternatively, CPS Investigations could be folded into the growing field of Forensic Social Work. In any case, a Masters-level specialization could be required in order to be a CPS worker, also adding a needed level of prestige to an important, difficult and hard-to-fill job.

Ideological Constraints

Inadequate resources might result in a random distribution of agency errors between those that involve too much intervention and those that involve too little. But the dominance of a particular ideology may skew the errors in one direction or another. And Garrett Therolf alludes to the rise of an ideology prioritizing family preservation nationwide and particularly in California during the years preceding Gabriel’s death. This ideology contributed to the decline in foster care numbers around the nation and particularly in Los Angeles, where Therolf reports the number of children in foster care fell from about 50,000 in 1998 to 19,000 in 2013. Much of this decline occurred during the tenure of DCFS administrator David Sanders, who later went on to lead Casey Family Programs, a foundation worth over two billion that has played an outsize role in national child welfare policy. The same year that Sanders took over at Casey, it declared a new goal to reduce the number of children in foster care by half by 2020.

Therolf was right to point a finger at Casey Family Programs. In my post about the death of two children by child abuse in Kansas, I wrote about how Casey leverages its massive wealth to affect policy directly, bypassing the voting public. It provides financial and technical assistance to state and local agencies, conducts research, develops publications, and provides testimony to promote its views to public officials around the country. Through its wealth in an underfunded field, Casey has been able to directly influence policy at the federal, state, and local levels.

Therolf points out that opinions on child welfare often cut across traditional political groupings. While Casey tends to support progressive causes, its emphasis on family preservation is often shared by conservatives who desire to reduce the government’s incursions on parental authority and at the same time to reduce spending. Working together, Casey and the George W. Bush administration created a waiver policy that allowed child welfare agencies to direct unused foster care funds toward family preservation services–a policy change which created an incentive to reduce the use of foster care. Therolf links this incentive to the drastic decline in the Los Angeles County foster care rolls between 1998 and 2013, stating that “When Gabriel came to the attention of DCFS, the chances of an abused child being placed in foster care were “lower than they’d been in many years.”

Perhaps all of the factors that led up to Gabriel’s death can be summed up by a striking statement by the supervisor on Gabriel’s case, who is currently standing trial in Gabriel’s death. He told Therolf that he had “concluded long ago that some of the children who depended on the department would inevitably be injured, if not killed.” He expressed frustration that administration and the public expected him to prevent all such deaths. This is not an acceptable attitude. It is true that a child welfare agency cannot prevent deaths among children who are unknown to the agency. But to expect that children will die under the agency’s watch–that is a low expectation indeed. We must do better by our most vulnerable children.

6 thoughts on “Why No One Saved Gabriel Fernandez”

I don’t think its fair to blame polices intended to keep families together and avoid the arbitrary nature of child welfare for Gabriel’s death. Because of the confidential nature of dependency, the public doesn’t see another crime that often occurs in child welfare, families being subject to the arbitrary conclusions of departments once they get in the system. The system is overloaded and the same faults that lead to Gabriel’s death also lead to families getting railroaded around one social workers opinion on a given case. The judicial system is often unable to protect these families because they rely so much on the departments assessment and have far too many cases to give the crucial attention each case needs. Gabriel’s case is a glaring and disturbing failure and was handled with ineptitude, but it shouldn’t be used as fodder against protecting families from a system that has not always offered them justice.

This is a brilliant analysis of how Alternative Response contributes to the death of children like Gabriel Fernandez. Let’s be clear, Alternative Response is not a professional social work theory backed up by evidence, it’s a political ideology supported by a wealthy foundation.

Thanks for the kind words, Rick. The brilliance is all borrowed from Garrett Therolf’s piece referenced in the post. But I don’t think that alternative response was involved here. Alternative response refers to using an “assessment” rather than an investigation, and I don’t even know if Los Angeles County uses that model. The original allegation received a traditional investigation, not an “assessment” per the differential response model. There were two problems: in the investigative phase, the allegation was not substantiated despite ample reason to do so. This is despite the fact that it was an investigation and not an assessment. I don’t know what happens in Minnesota, but normally an allegation like that made against Anthony’s mom would not be put on the alternative response track, which is supposed to be for lower-risk cases. The second problem was that the investigator chose to refer the family for voluntary services rather than go to court to request mandatory services. This was not because the family was referred to an alternative track to investigation, but it is certainly a similar issue and the general attitude behind this choice would be supported by the same people.

I have been a voluntary, family member caregiver over 2 years (caring for three children (when placed with me the youngest was a newborn male, a 2-and 6-year-old female) via a Power of Attorney (POA)–that was done at the local CPS location. The POA was not court-ordered and as soon as the mom understood that she was able to snatch her kids away, she did just that so today the kids are back in the turbulent, unsafe environments they came out of. After more than a year, the case involving drug abuse by the mother (different powerful drugs detected in the newborn’s blood stream at birth) the parental rights remained with the mother. The requested drug screens that have been ordered by CPS is, needless to say, been camouflaged by using other additives to hide the drugs in mom system. The CPS worker has been warned of this deplorable action, but nothing is being done to expose the additives that are being used and sold to drug addicts. As for getting help to protect the children’s welfare, the caseworker is overloaded with cases and the fear is that the children’s’ safety and well-being, once again, will slip through the cracks because the ultimate goal is to close the case and alleviate and close as many cases as possible and “save money”! Gabriel Fernandez’s life was cut short because too many short-cuts were taken–something must be done to truly “Protect the Children” from exploitation, neglect, and potentially dying because no one cared enough to zoom-in on what was happening behind the scenes of closed doors.

In my view, Gabriel Fernandez died because CPS caseworkers and supervisors did not recognize torture of a child when they encountered it, in part because of lack of training regarding the characteristics of torture and in part because torture of children is a low base rate phenomenon that even experienced practitioners rarely come upon in CPS investigations; and also because public agencies lack useful typologies of child maltreatment that can inform decision making.